Evaluating subconjunctival hemorrhage in the refractive era

August 2011‧Eye World

Evaluating subconjunctival hemorrhage in the refractive era

by Matt Young EyeWorld Contributing Editor



Subconjunctival hemorrhage (pictured here) can affect post-LASIK patient satisfaction Source: Rick Fraunfelder, M.D.


It may be a minor problem, but it's more significant for patients than some physicians think

   Although it's fairly innocuous, subconjunctival hemorrhage continues as an unwanted side effect among patients because of the unflattering eye redness that it causes after eye surgery.

   After glaucoma surgery, patients have a lot more to be concerned about than cosmesis. Did the procedure work? Will potential blindness be halted?

   But after an elective procedure like LASIK when patients expect superior outcomes, the "wow" effect could be diminished if they have incredible sight but aren't an incredible sight to look at. Patient satisfaction could be diminished after refractive cataract surgery for the same reason.

   It's therefore important to consider the fallout of subconjunctival hemorrhage in the refractive age and how to prevent it from happening.

A portion of cases

   Jay Bansal, M.D., medical director, LaserVue Eye Center, San Francisco, said subconjunctival hemorrhage is not a major issue, but it does exist. "I would say it's a problem in around 10-15% of [LASIK] cases," Dr. Bansal said.

   "I would also say it occurs around 10% of the time in cataract surgery."

   In LASIK, the problem surfaces more often with microkeratome usage, Dr. Bansal said. "Suction is higher with a microkeratome than with the femtosecond," Dr. Bansal explained.

   Dr. Bansal considers subconjunctival hemorrhage to be an entirely cosmetic problem and could impact how friends of LASIK patients receive them after surgery.

   "For coworkers and family, [subconjunctival hemorrhage] does take away from the 'wow' factor," said Dr. Bansal, whose point should not be taken lightly by clinicians banking on word-of-mouth referrals.

   There are ways to prevent subconjunctival hemorrhage. One is using vasoconstrictors prior to LASIK and post-op, he said. Reducing the amount of suction time also may help, he said. Another option is applying something cold over the eye prophylactically, like cold saline or an ice compress.

   Because it occurs in a minority of cases, Dr. Bansal said he is not in favor of discontinuing anticoagulants in LASIK patients. "At one point, we did ask all [cataract] patients to discontinue anticoagulants," Dr. Bansal said. "But with clear corneal surgery, we have gotten away from mandating this because we're not going through the conjunctiva anymore."

   That said, in other types of surgery such as retina or glaucoma surgery where the conjunctiva is being touched, Dr. Bansal's patients do discontinue anticoagulants.

Eye on anatomy

   "We should remember that subconjunctival hemorrhage is purely a cosmetic side effect 99.99% of the time with no visual or clinical significance," said Darrell White, M.D., president and CEO, Skyvision Centers of Westlake, Ohio. "It's significant only when the patient looks in the mirror or someone makes the observation."

   It's hard to avoid breaking small capillaries around the limbus during LASIK surgery, which results from suction, he said.

   "It has a lot to do with an individual's anatomy and how resilient his or her blood vessels are," Dr. White said. "If the patient has a wide-open orbit in a relatively prominent eye, it's easy to get whatever you're trying to get in quickly. The eye is right there for you and trauma is minimized. If the patient has a small eye or really deep orbit and you have to reseat the suction apparatus multiple times with suction going on and off, you increase the risk of a hemorrhage."

   He doesn't use vasoconstrictors before LASIK because they have the potential to interfere with surgery. "Theoretically, you don't want to use a vasoconstrictor before LASIK because you want to have a natural pupil," Dr. White said. All vasoconstrictors are at least weak dilators, he said, and dilated pupils make it difficult for patients to fixate, he said.

   Further, during intraocular surgery, when an instrument is being introduced inside the eye, the eye must be stabilized, Dr. White said.

   "You want to stabilize the eye so the only thing moving is the instrument and it goes in in a controlled fashion," Dr. White said. "If you grab the conjunctiva, you can cause a hemorrhage because the blood vessels are fragile. Coumadin (warfarin, Bristol-Myers Squibb, New York) blood thinner and aspirin increase the chance of bleeding. It can also become a subconjunctival hemorrhage when these patients don't stop bleeding as quickly."

   Trabeculectomy patients are always going to have some subconjunctival hemorrhage, Dr. White said. Strabismus patients have a similar problem "because you have gone through such a big area of vascular tissue," he said.

   "When I did more trabeculectomy, I always put in a drop of Neo-Synephrine [phenylephrine, Hospira, Lake Forest, Ill.]," Dr. White said. "That reduced capillary oozing and increased visualization."

   Hence, Dr. White recommends a vasoconstrictor like Neo-Synephrine be used in a dilation mix, whether as part of a series of eye drops, a soaked pledget, or a gel slurry.

   On the other hand, with topical anesthesia common during cataract surgery and with the majority of cataract surgery being clear corneal or near clear corneal, there's very little vascular tissue involved. In cataract surgery, such a vasoconstrictor may not be necessary.

   That said, whatever you do to ensure excellent outcomes both visually and cosmetically will be appreciated by premium IOL patients.

   "In cataract surgery with advanced implants, there are higher expectations," Dr. White said. "It feels more like LASIK. Many of us who do more of those advanced-implant styles tend to be a little more conscious of the cosmetic effect because it's a semi-elective procedure."

Editors' note: Drs. Bansal and White have no financial interests related to their comments.

Contact information

Bansal: 800-527-3745, bansal@laservue.com

White: 440-892-3931, cdunbar@skyvisioncenters.com